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Leading the Way to Better Patient Care
Business Journal

Leading the Way to Better Patient Care

by Jennifer Robison

Everyone at Cleveland Clinic is a caregiver, and it says so on their name badges. Whether an employee is a neurosurgeon, a nurse, a housekeeper, or a clerk who sells flowers at the gift shop, a Cleveland Clinic employee is a caregiver.

Engagement is crucial in any organization, but the stakes can be particularly high in healthcare.

Cleveland Clinic has always been dedicated to providing world-class clinical care. But like many healthcare organizations, Cleveland Clinic has been undergoing profound changes over the past few years -- hiring staff and doing layoffs, closing one facility and opening others -- all in the face of new industry regulations and a difficult economy.

Helping caregivers stay focused on giving patients the best possible care amid all this change could be a struggle. But the key, as Cleveland Clinic has come to realize, is the way employees view themselves and their roles. It makes all the difference, no matter what job they do.

Patients first

In 2008, Cleveland Clinic enlisted Gallup to support its employee engagement initiative. "The Cleveland Clinic has always been world renowned for its great clinical outcomes, but we needed it to also be known for its great service outcomes," says Chief Human Resources Officer Joe Patrnchak. "I don't think there's anybody yet that's been able to build a strong services organization without having a highly engaged workforce."

As part of the initiative, Gallup asked Cleveland Clinic's employees to rate their agreement with 12 items that reflect the crucial elements that drive employee engagement -- the Gallup Q12. The higher the score, the more engaged the workforce and, according to years of research, the better the performance. (See sidebar "The 12 Elements of Great Managing.")

Engagement is crucial in any organization, but the stakes can be particularly high in healthcare. "We've looked at engagement in hospitals and found that it is related to many important outcomes," says Jeff Durr, senior managing consultant for Gallup. "In a hospital with engaged staff, for example, there are fewer infections, fewer slips and falls, as well as less turnover and higher productivity."

But Cleveland Clinic's first engagement measures were not where its leaders wanted them. In 2008, Cleveland Clinic's overall engagement score ranked just below the 40th percentile in Gallup's healthcare database. For an organization that leads the U.S. in healthcare rankings, a less-than-excellent engagement level was unacceptable.

"Our guiding principle is 'patients first,' and employee engagement is a huge factor in that," says Senior Director, Employee Relations Jill Patterson. "There is a clear correlation between employees who are engaged and patient safety, outcome quality, and the patient experience. You have to be truly engaged to have these impacts. Unless you are engaged though, you're not going to have a positive impact on a patient or, quite frankly, your coworkers."

So, under the leadership of President and CEO Delos Cosgrove, M.D., Cleveland Clinic rolled out a new initiative that tied engagement to a broader culture shift. They called it the "Cleveland Clinic Experience," and it changed everything.

Inclusive leadership model

"The Cleveland Clinic Experience was a 42,000-person intervention," says Patrnchak. "You can't have a major change without a big idea. And the big idea was this notion that we're all caregivers."

Patrnchak partnered with James Merlino, M.D., Chief Experience Officer and the Office of Patient Experience to combine efforts to make the experience happen. That's when the name badges changed, as did a lot of other things.

"First, it was important to help everyone understand what engagement is, what it looks like, how to improve it, and to help everybody in the organization with the mechanics of it," Durr says. "Then Cleveland Clinic followed up by harvesting best practices and making engagement part of the DNA of the organization."

The 12 Elements of Great Managing

And that was just the beginning of the to-do list. Cleveland Clinic undertook a major shift to a more inclusive leadership model, and the employees created engagement action plans with their managers as part of that change. But one of the most effective changes came from a half-day seminar.

Leadership's investment in culture change was a wise one.

To pull off the training program, Cleveland Clinic had to coordinate seminars that included more than 40,000 employees in locations around the world, make sure that a cross section of employees attended every seminar, and bring up topics that had never been discussed before.

"I can't even begin to tell you how many different sessions there were," says Patterson. "But that was the first time that a mix of all caregivers sat at the same table to have a discussion about our culture, our priorities, and where we, as one Cleveland Clinic, are today and where we want to go."

It was a major feat that generated solid discussions. Among the key outcomes: Doctors learned that they have substantially more to do with the hospital's engagement than they'd realized; management learned that nurses can't access Q12 information online because they're rarely at a computer long enough to read it; and executives learned that administrative employees want to feel like they too are involved in making patients healthy.

Employees left the seminars feeling energized, motivated, and understood. They felt ready to be change agents. They felt recommitted to being the best caregivers in the world. It was a heady emotional experience -- and it could have petered out within days. Instead, Cleveland Clinic used the culture discussions as the start of something bigger.

Building engagement

"One of the things we learned from Gallup is that to grow engagement, you should start with a good impact plan," says Patrnchak. "So we helped managers and teams create impact plans and got everyone some coaching [on how to create a good plan]. To increase accountability, we developed some metrics to track the percentage of completed plans, and then we quality checked those plans."

Their analysis showed that only about 30% of the first impact plans met the clinic's goals and objectives. So HR decided its best option was to check every impact plan -- of which there were 4,828.

"It took a while, and I wouldn't want to make checking every impact plan a practice, but it helped managers build some competency and confidence," Patrnchak says. "And it also sent a very important message that we were serious about this, especially when we decided to heavily weight engagement in managers' performance management system."

The results of the second employee engagement survey indicated that despite the extra coaching, some teams' engagement levels weren't improving. So HR began to focus on the bottom 25% of managers, who needed the most coaching and education.

Meanwhile, Cleveland Clinic was building on the groundwork it had laid with the Cleveland Clinic Experience and its engagement efforts. It was challenging. Fundamental change is always tough, especially in complex organizations. "Driving change in a large organization that's steeped in tradition can be very difficult," Durr says. "For Cleveland Clinic's leadership to be effective, they needed to build on their reputation for world-class outcomes and explain the 'how' and the 'why' behind driving a culture of engagement."

By 2010, the time and effort had paid off, and employee engagement was on the increase. That made a difference to employees -- but it also made a difference in the hospital's patient ratings, as subsequent analysis of HCAHPS data showed.

The HCAHPS program was developed by the Agency for Healthcare Research and Quality to measure patient perceptions of inpatient hospital care and to enable the public to compare hospitals. Cleveland Clinic used Gallup's HCAHPS assessment to measure patients' perceptions of their healthcare experience and learned that there was a positive relationship between units with high employee engagement scores and patients' HCAHPS scores. In short, where employee engagement was high, HCAHPS scores were also likely to be high.

"The way engagement meshes with HCAHPS is profound," says Patterson. "And it's really important to let people know how significant it is -- that's why engagement isn't just a score. You have to be truly engaged to positively impact your patients on all levels."

A caring culture

In the fourth year of the culture shift, the Cleveland Clinic Experience and engagement as a core value were becoming a way of thinking -- and caregiving -- at Cleveland Clinic. The clinic stepped up recognition by implementing Caregiver Celebrations, a way that caregivers can be recognized by their peers and managers. It created new training opportunities and introduced new facilities to the concept of engagement and coached them to manage toward it. Leaders were made accountable for their employee engagement scores -- but in a way that was less tactical and score-oriented than it had been.

"We wanted [engagement] to become more cultural and conversational, and [we wanted] to emphasize the importance of action plans and having regular meetings with your employees. We really focused on how simple engagement can be," Patterson says. "It's not about data and reports; it's about communicating and understanding the importance of being engaged."

Cleveland Clinic also created its own "pulse" surveys to determine if managers were working on, and making progress on, their action plans. This was a good way to provide feedback to managers throughout the year and to keep the executive team informed about how the organization was progressing and about areas that may need improvement.

When the results of Cleveland Clinic's fourth survey came out, employee engagement had risen -- again. The increase showed that leadership's investment in culture change was a wise one. Cleveland Clinic's hard work was paying off, and the organization was benefitting substantially from its efforts.

But that's not the first thing employees recall when they think about the changes they've worked so hard to achieve. Instead, they think about that word on their name badges. "I know it seems like it could be a little thing, but thinking of yourself and everyone around you as a 'caregiver' is really meaningful," says Patterson. "We used to be employees, but now every single person in Cleveland Clinic is a caregiver. That's a powerful thing."


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